Traditional approaches to treatment of schizophrenia have tended to focus on symptom reduction, targeted behavioral goals, emotional regulation, and improved daily functioning.1,2 The psychosocial model of schizophrenia has long recognized the importance of an incremental skills-based approach in promoting recovery. Only recently has research indicated the importance of cognitive functioning for rehabilitation in schizophrenia.3-5 This article describes the use of different cognitive-based treatments by one New York provider of services to people with chronic mental illness, as well as discusses the importance of the assessment and measurement of cognitive interventions.
While the full extent of the role of cognitive processes in the treatment of schizophrenia still yet has to be established,4 many of the evidence-based practices widely disseminated by the New York Office of Mental Health incorporate everyday skills that draw upon basic cognitive processes, including illness management and recovery, family psychoeducation, supported employment, and integrated dual diagnosis treatment. All of these different evidence-based practices utilize cognitive skills such as the ability to learn new strategies, create social support networks, manage everyday activities (e.g., money management, using public transportation), manage symptoms, and improve education and knowledge.
Many diagnoses are included in definitions of severe and persistent mental illness (SPMI), typically schizophrenia, schizoaffective disorder, bipolar disorder, and depression. While these diagnoses differ widely in their symptomatology, they all appear to have a major impact on the cognitive processes of everyday life, often leading to lower functioning in work and social interactions.6 It is not clear that cognitive processes are a causal factor in mental illness, but certainly problems in cognition greatly exacerbate the symptoms of mental illness. These deficits compromise functioning and pose great challenges to recovery. This suggests that in a rehabilitation context, cognition needs to be an integral part of any intervention.
Incorporating Cognitive Interventions
FEGS is a not-for-profit human services agency with mental health programs throughout the New York metropolitan area, serving 18,000 people with mental illness annually. For the past eight years, FEGS has been committed to integrating the latest developments in cognitive interventions into all of its rehabilitation programs. This has meant developing extensive relationships with academic and clinical researchers in the field of cognition and mental illness, to provide modern tools and interventions to enhance clients' outcomes in rehabilitation programs.
The first steps to incorporating cognition in treatment initially were funded through a grant by the New York State Office of Mental Health and were focused on implementing cognitive remediation. Building upon this initiative, FEGS is developing further interventions for treating cognitive deficits, focusing on two important areas: first, assessment and measurement of cognitive processes and, second, improving individualized interventions to improve cognitive skills (e.g., cognitive remediation). This two-pronged approach is necessary to assess the impact of cognitive interventions on functional outcomes (e.g., achieving employment) in the SPMI population. FEGS recognizes the importance of underpinning any new treatment developments with a methodology for assessing and measuring outcomes.
Creating Cognitive Assessments
While we have used well-established methods of assessing symptomatology and its impact on activities of daily life, we recognize that this is not the same as ascertaining specific domains of cognitive deficits that may be impeding progress. We are working with leading researchers of cognitive assessment to introduce simple and useful performance-based assessments that can be administered by rehabilitation staff in 20 minutes.
In particular, Dr. Philip Harvey, professor of psychiatry at Mount Sinai School of Medicine, has worked on refining the cognitive assessment process, which can be more easily utilized in rehabilitation programs.7,8 We are working with him in the deployment of performance-based skills assessment in our rehabilitation programs, with the intention of using such assessments to direct service planning and intervention. These short assessments will allow us to quantify a variety of daily activity skills including communication skills and financial management and planning.